In Our Unit

An Enteral Nutrition Protocol to Improve

Efficiency in Achieving Nutritional Goals
Marian Racco, RN, MSN

I
n our intensive care unit (ICU), search. It was not surprising that (250 mL) should be considered
the “traditional order” for enteral the literature supported not only as a strategy to optimize deliv-
nutrition included 2 pieces of early initiation of enteral nutrition ery of enteral nutrition in criti-
information: in critical care patients, but also cally ill adult patients.1,4
• Formula timely achievement of nutritional • Protocols, algorithms, and
• Starting rate goals for the most favorable out- clinical practice guidelines
We were finding that the lack of comes for patients. According to the have been developed to stan-
standardization of the enteral nutri- literature, enteral nutrition proto- dardize enteral feeding prac-
tion order often resulted in patients cols facilitate the achievement of tice, and many have resulted
getting “stuck” at initiating rates of these goals: in an improvement in the
30 mL/h because the order was • Early enteral nutrition (within delivery of enteral feedings to
missing a rate of increase and a goal 24 to 48 hours) after admis- patients.1,6
rate. Additionally, the traditional sion into ICU is associated Based on the findings of the
order made no accommodations with decreased mortality.1-3 literature review, the ICU clinical
for those patients who experienced • Actual delivery of 60% to 70% coordinator designed an enteral
elevated gastric residual volumes of enteral feeding goals within nutrition protocol order set to
(GRVs), resulting in extended with- the first week of ICU admission address and correct the challenges
holding of feedings. The incomplete- is associated with a shortened we faced with the traditional initia-
ness of the traditional order for length of stay, shorter duration tion and delivery of enteral feedings
enteral nutrition set patients up to of mechanical ventilation, and (see Figure—available online only at
receive suboptimal nutrition. fewer infectious complications.4 www.ccnonline.org). The protocol
Inspired by the desire to provide • Use of enteral feeding proto- still required a physician’s order,
the best possible nutrition for our cols in ICUs promotes earlier but features designed to improve
critical care patients, the ICU clinical initiation of enteral feedings, efficiency were built into the proto-
coordinator conducted a literature increases the volumes of feed col, including the following:
delivered, optimizes number • Starting rate and incremental
of calories received, and results increase in rate, based on
Author
Marian Racco is the clinical coordinator
in shorter hospital stays and patient’s tolerance
of the intensive care unit at Hunterdon improved morbidity and mor- • Goal rate as set by dietitian
Medical Center in Flemington, New Jersey. tality outcomes.5 • Bowel management program
For questions related to this article, contact • In using enteral feeding pro- • Prokinetic agent was built into
Marian Racco at racco.marian@
hunterdonhealthcare.org. tocols, the incorporation of the order if the patient experi-
prokinetic agents at initiation enced 3 consecutive elevated
©2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ccn2012625 and tolerance of a higher GRV GRVs

72 CriticalCareNurse Vol 32, No. 4, AUGUST 2012 www.ccnonline.org

 The inclusion of these entities in
the order set was designed so that Table Comparison of results with and without use of enteral nutrition protocol
the critical care patient receiving
Enteral nutrition protocol Traditional method
enteral feedings would have every Result (n = 23) (n = 13)
chance to achieve target rates with-
Mean time to reach goal 12 34
out unnecessary delay. rate in patients without
The order set was presented to elevated GRV, hours
our ICU Quality Improvement Com- Mean time to reach goal 56.5 72
rate in patients with
mittee and the ICU Committee for elevated GRV, hours
approval and input from committee
Compliance in using 75 N/A
members, including the ICU med- “built-in” prokinetic Prokinetic agent used but
ical director, registered dietitian, ICU agent in patients with initiation delayed
elevated GRV, %
nurse director, and representatives
Abbreviations: GRV, gastric residual volume; NA, not applicable.
from the quality improvement depart-
ment. Once approved, it was impor-
tant to educate workers in those • The ICU enteral nutrition patients receiving enteral feedings in
disciplines that would be directly protocol order sets were the traditional manner included the
involved in its use: stocked in the bins in each following:
• Intensivists patient’s room. • Mean time to reach goal rate in
• ICU nurses • During the nutrition portion patients without elevated GRV
• Pharmacy staff of the morning rounds discus- • Mean time to reach goal rate
• Registered dietitians sion, the intensivist could initi- in patients with elevated GRV
Education was focused on the ate the enteral nutrition protocol • For patients on the protocol
major points in the protocol that or initiate enteral feedings in and with elevated GRV, compli-
were a change in current practice, the traditional method. Round- ance with the built-in proki-
such as ing ICU nurses and the ICU netic agent use was measured
• Built-in progressive rate clinical coordinator were • For patients receiving enteral
increase encouraged to remind the feedings in the traditional
• Built-in bowel regimen intensivists of the protocol. manner and with elevated
• Prokinetic agent • If the intensivist activated the GRV, it was noted if a proki-
• Protocol requires physician’s protocol, the dietitian would netic agent was used at all
order to initiate, but registered immediately write in the appro- A total of 36 patients were
dietitian to set the goal priate goal for the patient. reviewed. Twenty-three patients sur-
As is frequently the case with • The order set would be scanned veyed were on the enteral nutrition
change, it takes time for the team to and sent to the pharmacy in protocol, and 13 patients received
regularly incorporate the change into the same manner as all other enteral feedings in the traditional
their practice. Regular use of the orders, and the bowel regimen manner (see Table).
enteral nutrition protocol order set and the prokinetic agent The enteral nutrition protocol
was no different. Intensivists would would then be included in the was more efficient in achieving
sometimes forget to use it and resort patient’s medication adminis- nutritional goals than the tradi-
to the traditional method of ordering tration record. tional method of initiation and
enteral feedings. This however, pro- Data collection was completed delivery of enteral feedings in criti-
vided an opportunity for the ICU by the ICU clinical coordinator. cal care patients, as evidenced by
clinical coordinator to compare both Chart reviews were done on patients the following:
methods directly in terms of their receiving enteral feedings. Data col- • Protocol patients without
efficiency in achieving nutritional lected for both patients on the elevated GRV reached goal
goals. The procedure was as follows: enteral nutrition protocol and rates in about one-third the
Continued on page 75

www.ccnonline.org CriticalCareNurse Vol 32, No. 4, AUGUST 2012 73

 time of nonprotocol patients patients. J Am Diet Assoc. 2006;106(8):
1226-1241.
(12 hours vs 34 hours). 5. Dobson K, Scott A. Review of ICU nutrition
support practices: Implementing the nurse-
• Protocol patients with ele- led enteral feeding algorithm. Nurs Crit Care.
vated GRV reached goal rates 2007;12(3):114-123.
6. Marshall AP, West SH. Enteral feeding in
16 hours sooner than nonpro- the critically ill: Are nursing practices con-
tributing to hypocaloric feeding? Intensive
tocol patients (56.5 hours vs Crit Care Nurs. 2006;22(2):95-105.
72 hours).
• Protocol patients were started
on the prokinetic agent after 3
consecutive elevated GRVs
75% of the time. Only 1 patient
receiving enteral feedings in
the traditional manner experi-
enced elevated GRV. It took
almost 3 days of feeding intol-
erance before a prokinetic agent
was started for that patient.
In our ICU, initiating an enteral
nutrition protocol has enabled our
patients to achieve nutritional goals
sooner than the standard method of
initiation and delivery of enteral
feedings. This is significant as the
literature supports early nutrition
in the critical care environment
because it decreases infectious com-
plications, duration of mechanical
ventilation, length of stay, and mor-
bidity and mortality. CCN

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Financial Disclosures
None reported.

References
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tocol: enteral feedings for critically ill

75 CriticalCareNurse Vol 32, No. 4, AUGUST 2012 www.ccnonline.org